Archived August 2005

Case Study 2 - West Gippsland Hospital

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Background

The Mornington Peninsula Hospital is a 382-bed hospital providing acute medical and surgical services, midwifery services and acute psychiatric services. The hospital has two main campuses, one at frankston and a smaller 38-bed campus at Rosebud. A further 34 beds were scheduled to be opened in October 1995.

The current Chief Medical Records Administrator (MRA) at Mornington Peninsula Hospital is Linda Fletcher. Linda commenced work as the Chief MRA at Mornington Peninsula Hospital just one week before the date of commencement of case mix funding on 1 July 1993. The preparation for the changes in regard to reporting of Aboriginality was undertaken by the previous Chief MRA.

Organisational/Reporting Structure

At the time that the changes in reporting Aboriginality were introduced, the Chief MRA was not responsible for the elective admissions staff or for staff undertaking admissions in the Accident and Emergency Department of the hospital. Where the changes being introduced on the 1 July 1993 concerned staff in other areas, the responsibility was shared between the managers of relevant sections of the hospital and the Chief MRA. The Chief MRA took the responsibility for overseeing that the changes actually happened in all relevant sections of the hospital.

Since February 1995, staff undertaking admissions in the Accident and Emergency area report directly to the Chief MRA. Staff responsible for elective admissions now report to the Waiting List Manager.

Staff Information Sessions

Clerical staff at the hospital were advised of the changes to commence on 1 July 1993 at staff information sessions.

The magnitude of the changes associated with the introduction of case mix funding were overwhelming. At the information sessions, the clerical staff would have been told about the new field for recording Aboriginality but Linda said,

''The requirement for recording of Aboriginality may have had minimal impact on the staff because of the massive changes associated with case mix funding and other VIMD reporting requirements..."

Initial Computer Changes

At this hospital, the software changes required for 1 July 1993 were not ready in time. These changes were not completely in place until approximately mid-August 1995. The computer field to record Aboriginality was not established as a mandatory field, and the Aboriginality question could be by-passed. If there was nothing recorded in this field it was assumed that the patient was non-Aboriginal. Linda said,

'We were probably a bit slow to realise the importance of the Aboriginality reporting because of the magnitude of the changes for 93-94. The focus was on the implementation of new systems to cope with case mix'.

Initial Survey

In January 1994, the Chief Executive Officer was notified that Mornington Peninsula Hospital was one of the hospitals selected to be involved in the telephone survey of MRAs, to be undertaken by the Koori Health Unit to monitor the implementation of mandatory recording of Aboriginality.

At the time of the initial survey, the Chief MRA was aware that some staff were not happy about asking the Aboriginality question. She had followed up these concerns with discussions with staff in the Admissions area and the Accident and Emergency Department.

Staff reported that some patients and family members had strongly objected to the Aboriginality question. Even the teenage son of one patient had objected to his mother being asked the Aboriginality question. Some staff had reported that patients considered that the question was 'racist'. Other patients had asked if the question was being asked 'so the hospital could get more money'.

The Chief MRA reported that the response of staff to the requirement to ask the Aboriginality question varied with individual staff members. However, overall the question was regarded as being highly sensitive and she considered that it was very likely that the Aboriginality question was often not asked.

The Chief MRA acknowledged that staff education and public education were needed. Clerical staff were not sure why the Aboriginality question was being asked and they did not know how to respond when a patient objected to the question. Staff said that they felt happier when the Aboriginality question was on a form, and then they did not have to ask the question directly.

Initial Survey Report

MRAs from the Acute Health Section of Human Services distributed the report of the initial survey directly to hospital MRAs with the Koori Health Unit's posters and pamphlets and information sheets, at update sessions held in August 1994.

The direct distribution was appreciated because at times there can be delays in staff receiving relevant documents when the documents are sent via the formal organisational structure.

Action Taken on Initial Survey Report

On receiving the survey report Linda, wrote to the hospital's computer systems manager and to the manager of the Patient Reception Unit. She provided details of the relevant recommendations which needed action to be taken by these staff as a basis for discussions on the implementation of the recommendations of the survey report.

Linda said that knowing that there was to be a follow-up survey was a help. The follow-up survey implied: 'This is a serious thing-not just rhetoric. We are going to be held accountable'. It meant that Linda could write to the computer systems manager recommending the computer changes, and decisions in regard to cost of the changes could be made by the hospital executive.

1. Hospital Forms

   Subsequent to the initial survey, there were no changes required to forms at this hospital. Provision for recording Aboriginality on the hospital registration form completed by patients, and in the pre-admission letters used for elective admissions, had already been made prior to the 1 July 1993 changes.

2. Staff Training

   At Mornington Peninsula Hospital, there are staff responsible for undertaking admissions in the Accident and Emergency Department, the Admissions area, Midwifery, and at the Rosebud campus.

   Linda said that clerical staff training at this hospital needed to be able to take into account the large numbers of staff involved. At this hospital, there are fifteen staff undertaking admissions in the Accident and Emergency Department alone. Staff involved in admissions throughout the hospital are working without close supervision. Staff undertaking admissions are rostered to cover a 24-hour day and there are frequently new staff to be trained.

   Linda said,

   'I took the stand that the recording of Aboriginality is a mandatory requirement of the Department of Health and Community Services and if it has to be done and we are going to be audited, then it has to be done properly'.

   Linda decided that the training in regard to recording of Aboriginality should be on a one-to-one basis. It was not possible to bring all staff together for training because it was not possible to close down the Accident and Emergency Admissions Section, and many staff worked shifts to cover the 24-hour period over seven days a week.

   Linda felt that although information was continually being sent out to staff, more impact would be obtained by a personal visit. She said,

   'A personal visit to staff is of course labour intensive, but it is quicker and more effective to have a ten minute visit to individual staff, and ask them to pass the information on to the next shift'.

   Linda would then follow up with staff the next day to ensure that the information had been passed on.

   Linda's approach to staff was, 'Can you show me how you are using the Aboriginality field (on the computer system)?', rather than asking the staff if they were asking the Aboriginality question.

   After the initial contacts with clerical staff, she realised that the Aboriginality field was being bypassed and that the real problem was that the staff were not comfortable with asking the Aboriginality question. Copies of all the information and public relations material which had been sent from the Koori Health Unit, were then given to all staff responsible for undertaking admissions in relevant areas of the hospital. Linda and the manager responsible for the Patient Reception Unit took the same position as stated in the promotional material provided by the Koori Health Unit.

   Linda said,

   'I made it very clear that it was essential to take a strong stand or we would have no hope. It was just that asking about Aboriginality was new and unfamiliar to our staff. We introduced a form for staff who were reluctant to actually ask the question, as our way of compensating for staff who just refused to ask the question. We couldn't allow any staff to refuse to ask the question because we knew that then the other staff would not comply either. We knew that the staff who were not complying would eventually affect the others. You have to make sure that everyone follows the same rules, or the general feeling is "If other people are not asking this question, then why should I...".'

   Linda also continually stressed the importance of the recording of Aboriginality to the managers responsible for staff undertaking admissions in the Accident and Emergency Department and the Admissions area. She kept checking that the appropriate information about recording Aboriginality was being disseminated to all staff and that staff compliance was being monitored.

   Linda said that it is sometimes easier to get staff compliance for a particular change if you are able to say that it is a Human Services requirement. Now that current staff feel comfortable about the Aboriginality question, training of new staff regarding recording Aboriginality will be easier.

   Staff training is usually done one-to-one by experienced clerks. Aboriginality is now just part of the overall training. Linda said that Admission staff training for the future will make use of the information provided by the Koori Health Unit and publications distributed by MRAs from the Acute Health Division of Human Services.

3. Computer System Changes

   Linda acknowledged that because large numbers of staff work around the clock undertaking admissions, it is important that the computer system is set up so that the computer system itself can help resolve problems in recording Aboriginality.

   After discussions with the computer systems manager, the following changes to the hospital's computerised patient records system were recommended:

   • Changing the name of the field on the registration screen from 'Ethnicity' to 'Aboriginality'.
   • Changing the reporting of this field to being a mandatory field.
   • Changing the value applicable to this field from 'A' or 'blank' to 'Y' or 'N'.
   • Changing the field so that the values in it are not retained permanently but rather that they are required to be updated at each admission.
   • Although not considered to be absolutely necessary, to have the field transferred to the Admissions Screen, rather than retained as a permanent data item on the PMI.

   These recommendations were then put formally to the hospital executive to see if the hospital was able to implement these changes. The hospital executive asked the computer systems manager to provide the necessary changes. He then contacted the software company to request a quotation.

   The computer systems manager also contacted other hospitals who used the same computer system via the network of user group members, to see if they would be willing to be involved in the changes. If the user group was supportive of the changes then the possibility of reduced costs could be explored, by implementing the required changes at all of the hospitals using this particular computer system.

   Unfortunately, the members of the computer system user group did not regard the changes for recording Aboriginality as a priority issue. This meant that compliance with Human Services requirements for changes to the computer software system at this hospital were cost-prohibitive.

   The only change to the computer system achieved at Mornington Peninsula Hospital without cost was changing the name of the field for recording the response to the Aboriginality question from 'Ethnicity' to 'Aboriginality'.

4. Quality Assurance Audit

   A quality assurance audit was undertaken by contacting social work staff in regard to patients who they knew to be of Aboriginal or Torres Strait Islander descent. The audit showed that all patients reported by social work staff as being of Aboriginal or Torres Strait Islander descent had been correctly recorded at the time of admission.

   Linda said that it would be possible to track back and find out where a problem of recording Aboriginality had actually occurred. If a discrepancy in the reporting of Aboriginality had been found, Linda would have arranged a group meeting with staff responsible for undertaking admissions from either the Admissions area or Accident and Emergency Department, depending on where the problem had arisen.

   Linda said that she would have used the meeting as a 'friendly reminder' at a group level, in regard to recording Aboriginality. In the absence of a Koori Hospital Liaison Officer at this hospital, this is how a quality assurance check on the Aboriginality data item would be handled in the future.

   Possible Interim VIMD Coding Errors for the Aboriginality Data Item

   In June 1995, a letter from the Human Services Regional Office raised concerns in regard to possible errors in recording of Aboriginality from interim VIMD data received from hospitals for 1994-95. However, the Regional Office did not provide information on specific admissions at specific hospitals to be identified.

   A cross-check of patients recorded as being Aboriginal at Mornington Peninsula Hospital for 1994-95 showed that none of these patients were recorded as being born in a country other than Australia. As Aboriginality of patients is still stored as a data item on the Patient Master Index database at this hospital, it was not possible to check back as to whether any patients had been recorded as having different Aboriginality status for a previous admission.

   Outcomes and Achievements

   At the time of the follow-up survey Linda reported that an improvement in the way the information on Aboriginality was collected at Mornington Peninsula Hospital had been achieved by 'intensive staff consultation, training and follow-up'.

   Staff members had gained confidence and on the whole, they were now more comfortable with asking patients about Aboriginality. A specific form had initially been designed for staff who may still be uncomfortable with asking the patient the Aboriginality question. The patient was asked to fill in the form so that the information could then be entered onto the computer system.

   It is of interest that the specific form for recording Aboriginality is no longer in use, as all staff are now comfortable with actually asking patients the Aboriginality question.

   Possible Alternative Approaches

   Linda said that it would not have been appropriate to say to staff

   'The hospital has signed a funding agreement that says that every patient will be asked if they are of Aboriginal or Torres Strait Islander descent, so if you are not asking the question then you are not doing your job'.

   She said that taking a harder stand just would not have worked. The staff would have said that they were asking the question, but they would still not have asked. As the staff undertaking admissions are working without close supervision, it is important to know that the approach taken will achieve the required response and action from all relevant staff, 24-hours a day, seven days a week.

   Other Issues

   Linda said that it would have been much easier to comply with Human Services reporting requirements and implementation of the necessary computer software changes, if payment was offered by the Department either directly to individual hospitals or to the computer software user group.

   Costs could be reduced by a bulk change being put in place at all hospitals who used a particular software system. There should be negotiation between the Department and software user-groups to enable changes to be made most cost-effectively.

   Most of the staff involved in undertaking admissions have been very compliant and very reliable. Linda said,

   'On the whole, staff involved in the Admissions procedure at Mornington Peninsula Hospital have been very compliant and reliable. Every year we ask our staff to adopt changes to comply with Human Services requirements, and administratively we are asking for more and more data with each year that passes. At Mornington Peninsula Hospital, we have an integrated psychiatric service now and I think that the changes that have been brought about as a result have also exposed our staff to another aspect of health service delivery. We have a lovely group of mature ladies who understand what is required of them, and generally, if what is required makes sense, then our staff are happy to comply'.